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<!DOCTYPE HTML>
<html xmlns:th="http://www.thymeleaf.org">
<head>
	<link rel="stylesheet" type="text/css" th:href="@{css/records/records.css}" />
	<title>产科入院护理评估单</title>
</head>
<body>
	<article class="cl">
		<form action="" method="post" class="form form-horizontal"
			id="form-admin-add">
			<div class="row cl">
				<div class="formControls col-sm-12">
					<h4>一、一般资料</h4>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>性别：</label><input type="text" class="txt" value=""
						placeholder="" id="性别" />
				</div>
				<div class="formControls col-sm-3">
					<label>年龄：</label><input type="text" class="txt" value=""
						placeholder="" id="年龄" />
				</div>
				<div class="formControls col-sm-3">
					<label>职业：</label><input type="text" class="txt" value=""
						placeholder="" id="职业" />
				</div>
				<div class="formControls col-sm-3">
					<label>民族：</label><input type="text" class="txt" value=""
						placeholder="" id="民族" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>籍贯：</label><input type="text" class="txt txtw" value=""
						placeholder="" id="籍贯" />
				</div>
				<div class="formControls col-sm-3">
					<label>文化程度：</label><input type="text" class="txt" value=""
						placeholder="" id="文化程度" />
				</div>
				<div class="formControls col-sm-3">
					<label>宗教：</label><input type="text" class="txt" value=""
						placeholder="" id="宗教" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>婚姻状况：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="婚姻状况:已婚"/> <label
							for="婚姻状况:已婚">已婚</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="婚姻状况:未婚" name="sex"/> <label
							for="婚姻状况:未婚">未婚</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="婚姻状况:离异"/> <label
							for="婚姻状况:离异">离异</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="婚姻状况:其他" name="sex"/> <label
							for="婚姻状况:其他">其他</label>
					</div>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>家庭地址：</label> <input type="text" class="txt txtWidth800"
						value="" placeholder="" id="家庭地址" />
				</div>
			</div>

			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>联系人：</label><input type="text" class="txt" value=""
						placeholder="" id="联系人" />
				</div>
				<div class="formControls col-sm-3">
					<label>与患者关系：</label><input type="text" class="txt" value=""
						placeholder="" id="与患者关系" />
				</div>
				<div class="formControls col-sm-3">
					<label>联系电话：</label><input type="text" class="txt" value=""
						placeholder="" id="联系电话" />
				</div>
			</div>



			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>入院时间：</label><input type="text" class="txt txtw" value=""
						placeholder="" id="入院时间" />
				</div>
				<div class="formControls col-sm-4">
					<label>通知医师时间：</label><input type="text" class="txt" value=""
						placeholder="" id="通知医师时间" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>入院方式：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="入院方式:步行"/> <label
							for="入院方式:步行">步行</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院方式:扶助" name="sex"/> <label
							for="入院方式:扶助">扶助</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="入院方式:轮椅"/> <label
							for="入院方式:轮椅">轮椅</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院方式:平车" name="sex"/> <label
							for="入院方式:平车">平车</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院方式:背送" name="sex"/> <label
							for="入院方式:背送">背送</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="入院方式:抱送"/> <label
							for="入院方式:抱送">抱送</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院方式:其他" name="sex"/> <label
							for="入院方式:其他">其他</label>
					</div>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>入院陪送：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="入院陪送:家人"/> <label
							for="入院陪送:家人">家人</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院陪送:朋友" name="sex"/> <label
							for="入院陪送:朋友">朋友</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="入院陪送:其他" name="sex"/> <label
							for="入院陪送:其他">其他</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="入院陪送:其他内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>入院诊断：</label> <input type="text" class="txt txtWidth800"
						value="" placeholder="" id="入院诊断" />
				</div>
			</div>

			<div class="row cl">
				<div class="formControls col-sm-12">
					<h4>二、健康评估</h4>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>既往病史：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="既往病史:无"/> <label
							for="既往病史:无">无</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="既往病史:住院" name="sex"/> <label
							for="既往病史:住院">住院</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="既往病史:手术" name="sex"/> <label
							for="既往病史:手术">手术</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="既往病史:所患疾病名称" name="sex"/> <label
							for="既往病史:所患疾病名称">所患疾病名称</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="既往病史:所患疾病名称内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>&#12288;过敏史：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="过敏史:无"/> <label
							for="过敏史:无">无</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="过敏史:有" name="sex"/> <label
							for="过敏史:有">有</label>
					</div>
					<label class="pl-20">过敏药物：</label><input type="text"
						class="txt txtWidth200" value="" placeholder="" id="过敏史:过敏药物"
						/> <label class="pl-20">过敏食物：</label><input
						type="text" class="txt txtWidth200" value="" placeholder=""
						id="过敏史:过敏食物" /> <label class="pl-20">其他：</label><input
						type="text" class="txt txtWidth200" value="" placeholder=""
						id="过敏史:其他" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>饮食习惯：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="饮食习惯:正常"/> <label
							for="饮食习惯:正常">正常</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="饮食习惯:异常" name="sex"/> <label
							for="饮食习惯:异常">异常</label>
					</div>

				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;嗜好：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="嗜好:烟"/> <label
							for="嗜好:烟">烟</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="嗜好:酒" name="sex"/> <label
							for="嗜好:酒">酒</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="嗜好:其他" name="sex"/> <label
							for="嗜好:其他">其他</label>
					</div>

				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;睡眠：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="睡眠:正常"/> <label
							for="睡眠:正常">正常</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="睡眠:入睡困难" name="sex"/> <label
							for="睡眠:入睡困难">入睡困难</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="睡眠:易醒" name="sex"/> <label
							for="睡眠:易醒">易醒</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="睡眠:药物" name="sex"/> <label
							for="睡眠:药物">药物</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="睡眠:药物内容" >
					<div class="cbx">
						<input type="checkbox" id="睡眠:其他" name="sex"/> <label
							for="睡眠:其他">其他</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="睡眠:其他内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;大便：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="大便:正常"/> <label
							for="大便:正常">正常</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:便秘" name="sex"/> <label
							for="大便:便秘">便秘</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:腹泻" name="sex"/> <label
							for="大便:腹泻">腹泻</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:造痿" name="sex"/> <label
							for="大便:造痿">造痿</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:便血" name="sex"/> <label
							for="大便:便血">便血</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:陶土便" name="sex"/> <label
							for="大便:陶土便">陶土便</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:失禁" name="sex"/> <label
							for="大便:失禁">失禁</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="大便:其他" name="sex"/> <label
							for="大便:其他">其他</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="大便:其他内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;小便：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="小便:正常"/> <label
							for="小便:正常">正常</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="小便:尿失禁" name="sex"/> <label
							for="小便:尿失禁">尿失禁</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="小便:尿潴留" name="sex"/> <label
							for="小便:尿潴留">尿潴留</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="小便:外引流" name="sex"/> <label
							for="小便:外引流">外引流</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="小便:其他" name="sex"/> <label
							for="小便:其他">其他</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="小便:其他内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>肢体活动：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="肢体活动:自如"/> <label
							for="肢体活动:自如">自如</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="肢体活动:障碍" name="sex"/> <label
							for="肢体活动:障碍">障碍</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="肢体活动:障碍内容" />
					<div class="cbx">
						<input type="checkbox" id="肢体活动:瘫痪" name="sex"/> <label
							for="肢体活动:瘫痪">瘫痪</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="肢体活动:瘫痪内容" />
				</div>
			</div>

			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>生命体征：&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</label> <label>体温：</label><input
						type="text" class="txt txtWidth100" value="" placeholder=""
						id="体温" /> <label>℃</label>
				</div>
				<div class="formControls col-sm-2">
					<label>脉搏：</label><input type="text" class="txt txtWidth100"
						value="" placeholder="" id="脉搏" /> <label>次/分</label>
				</div>
				<div class="formControls col-sm-2">
					<label>呼吸：</label><input type="text" class="txt txtWidth100"
						value="" placeholder="" id="呼吸" /> <label>次/分</label>
				</div>
				<div class="formControls col-sm-2">
					<label>血压：</label><input type="text" class="txt txtWidth100"
						value="" placeholder="" id="血压" /> <label>mmHg</label>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>意识状态：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="意识状态:清醒"/> <label
							for="意识状态:清醒">清醒</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="意识状态:嗜睡" name="sex"/> <label
							for="意识状态:嗜睡">嗜睡</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="意识状态:昏睡"/> <label
							for="意识状态:昏睡">昏睡</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="意识状态:浅昏迷" name="sex"/> <label
							for="意识状态:浅昏迷">浅昏迷</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="意识状态:深昏迷"/> <label
							for="意识状态:深昏迷">深昏迷</label>
					</div>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>皮肤完整性：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="皮肤完整性:完整"/> <label
							for="皮肤完整性:完整">完整</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="皮肤完整性:破损" name="sex"/> <label
							for="皮肤完整性:破损">破损</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="皮肤完整性:压疮"/> <label
							for="皮肤完整性:压疮">压疮</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="皮肤完整性:其他" name="sex"/> <label
							for="皮肤完整性:其他">其他</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="皮肤完整性:其他内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>自理能力：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="自理能力:无需依赖"/> <label
							for="自理能力:无需依赖">无需依赖</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="自理能力:轻度依赖" name="sex"/> <label
							for="自理能力:轻度依赖">轻度依赖</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="自理能力:中度依赖"/> <label
							for="自理能力:中度依赖">中度依赖</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="自理能力:重度依赖" name="sex"/> <label
							for="自理能力:重度依赖">重度依赖</label>
					</div>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>压疮评估：</label>
					<div class="cbx">
						<input name="sex" type="checkbox" id="压疮评估:无危险"/> <label
							for="压疮评估:无危险">无危险</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="压疮评估:低度危险" name="sex"/> <label
							for="压疮评估:低度危险">低度危险</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="压疮评估:中度危险"/> <label
							for="压疮评估:中度危险">中度危险</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="压疮评估:高度危险" name="sex"/> <label
							for="压疮评估:高度危险">高度危险</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="压疮评估:极度危险" name="sex"/> <label
							for="压疮评估:极度危险">极度危险</label>
					</div>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>跌倒/坠床评估：</label>
					<div class="cbx">
						<input type="checkbox" id="跌倒/坠床评估:低度危险" name="sex"/> <label
							for="跌倒/坠床评估:低度危险">低度危险</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="跌倒/坠床评估:中度危险"/> <label
							for="跌倒/坠床评估:中度危险">中度危险</label>
					</div>
					<div class="cbx">
						<input type="checkbox" id="跌倒/坠床评估:高度危险" name="sex"/> <label
							for="跌倒/坠床评估:高度危险">高度危险</label>
					</div>
				</div>
			</div>

			<div class="row cl">
				<div class="formControls col-sm-12">
					<h4>三、专科评估</h4>
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>受孕情况：</label>
					<div class="cbx">
						<label for="受孕情况:孕">孕</label> <input style="width: 30px"
							name="sex" type="text" id="受孕情况:孕"/><label>次</label>
					</div>
					<div class="cbx">
						<label for="受孕情况:产">产</label> <input style="width: 30px"
							name="sex" type="text" id="受孕情况:产"/><label>次</label>
					</div>
					<div class="cbx">
						<label for="受孕情况:人流">人流</label> <input style="width: 30px"
							name="sex" type="text" id="受孕情况:人流"/><label>次</label>
					</div>
					<div class="cbx">
						<label for="受孕情况:存">存</label> <input class="txtWidth100"
							name="sex" type="text" id="受孕情况:存"/>
					</div>

				</div>
			</div>

			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>末次月经：</label><input type="text" class="txtWidth200" value=""
						placeholder="" id="末次月经" />
				</div>
				<div class="formControls col-sm-4">
					<label>预产期：</label><input type="text" class="txtWidth100" value=""
						placeholder="" id="预产期" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>阴道流血：</label>

					<div class="cbx">
						<input type="checkbox" id="阴道流血:无" name="sex"/> <label
							for="阴道流血:无">无</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="阴道流血:有"/> <label
							for="阴道流血:有">有</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="阴道流血:有内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>阴道流液：</label>

					<div class="cbx">
						<input type="checkbox" id="阴道流液:无" name="sex"/> <label
							for="阴道流液:无">无</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="阴道流液:有"/> <label
							for="阴道流液:有">有</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="阴道流液:有内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-12">
					<label>子宫收缩：</label>

					<div class="cbx">
						<input type="checkbox" id="子宫收缩:无" name="sex"/> <label
							for="子宫收缩:无">无</label>
					</div>
					<div class="cbx">
						<input name="sex" type="checkbox" id="子宫收缩:有"/> <label
							for="子宫收缩:有">有</label>
					</div>
					<input type="text" class="txt txtWidth300" value="" placeholder=""
						id="子宫收缩:有内容" />
				</div>
			</div>
			<div class="row cl">
				<div class="formControls col-sm-11">
					<label>其他专科情况</label>
					<textarea name="" cols="" rows="" class="textarea" placeholder=""
						 onKeyUp="textarealength(this,100)" id="其他专科情况"></textarea>
					<p class="textarea-numberbar">
						<em class="textarea-length">0</em>/1000
					</p>
				</div>
			</div>


			<div class="row cl">
				<div class="formControls col-sm-3">
					<label>评估护士：</label><input type="text" class="txt txtw" value=""
						placeholder="" id="评估护士" />
				</div>
				<div class="formControls col-sm-4">
					<label>评估时间：</label><input type="text" class="txt" value=""
						placeholder="" id="评估时间" />
				</div>
			</div>
			<br />
			<br />
			<br />
			<br />
		</form>
	</article>
	<!--请在下方写此页面业务相关的脚本-->
	<script type="text/javascript" th:src="@{hui-ui/lib/jquery.validation/1.14.0/jquery.validate.js}"></script>
	<script type="text/javascript" th:src="@{hui-ui/lib/jquery.validation/1.14.0/validate-methods.js}"></script>
	<script type="text/javascript" th:src="@{hui-ui/lib/jquery.validation/1.14.0/messages_zh.js}"></script>
	<script type="text/javascript">
		$(function() {
			$('.skin-minimal input').iCheck({
				checkboxClass : 'icheckbox-blue',
				radioClass : 'iradio-blue',
				increaseArea : '20%'
			});

			$("#form-admin-add").validate({
				rules : {
					adminName : {
						required : true,
						minlength : 4,
						maxlength : 16
					},
					password : {
						required : true,
					},
					password2 : {
						required : true,
						equalTo : "#password"
					},
					sex : {
						required : true,
					},
					phone : {
						required : true,
						isPhone : true,
					},
					email : {
						required : true,
						email : true,
					},
					adminRole : {
						required : true,
					},
				},
				onkeyup : false,
				focusCleanup : true,
				success : "valid",
				submitHandler : function(form) {
					$(form).ajaxSubmit();
					var index = parent.layer.getFrameIndex(window.name);
					parent.$('.btn-refresh').click();
					parent.layer.close(index);
				}
			});
		});
	</script>
	<!--/请在上方写此页面业务相关的脚本-->
</body>
</html>